THE ORIENTAL INSURANCE COMPANY LIMITED

Transcription

1 1 THE ORIENTAL INSURANCE COMPANY LIMITED Regd. Office : Oriental House, P.B. No. 7037, A-25/27, Asaf Ali Road, New Delhi CIN No.U66010DL1947GOI MEDICLAIM INSURANCE POLICY (INDIVIDUAL)- PROSPECTUS 1. SALIENT FEATURES OF THE POLICY (i) (ii) (iii) (iv) (v) (vi) The Policy term is one year and is available to any proposer between the age of 18 to 65 years for treatment taken in India. The proposer can also get his family covered (as defined under 2.1). Maximum Entry age for any member, is 65years however, this can be extended upto 70 years. In such case, an additional premium of 10% (including on all future renewals) will be charged on applicable rates, including on Optional PA cover. Sum Insured (SI) available from Rs.1lac to Rs.10lacs. Pre-existing diseases covered after four consecutive renewals. Life long renewals allowed. Family discount of 10% (including on PA cover) if more than one person is covered under the policy. (vii) Option of voluntary co-payment of 10% and 20% with corresponding premium discount of 10% and 20% respectively on SI of Rs.2lacs and above. Voluntary co-payment does not apply on PA section. (viii) (ix) (x) (xi) (xii) (xiii) (xiv) (xv) (xvi) (xvii) No medical examination for persons upto the age of 55 years. In case of fresh covers, 50% of the Pre-insurance medical check-up cost reimbursable, subject to acceptance of the Proposal. Daily Hospital Cash allowance in case of more than 2 days of continuous hospitalisation. Hospitalisation expenses incurred for donating an organ by the donor (excluding cost of organ) to the insured person, is covered Ambulance charges covered Personal Accident available on optional basis for SI from Rs.2lacs to Rs.10lacs. Free Look Period- A period of 15 days from the date of receipt of the policy to review the terms and conditions of the policy and return the same, if not acceptable. Grace period of 30 days is allowed for payment of renewal premium. Premium adjustment at renewal, for the duration of OMP cover taken from Oriental. Discount of 5.5% in premium if TPA services not opted for. 2.1 DEFINITION OF FAMILY (i) (ii) Family consists of the proposer and any one or more of the family members as mentioned below: legally wedded spouse. dependent Children (i.e. natural or legally adopted) between the age 3months to 18 years. However male child can be covered upto the age of 25 years if he is a bonafide regular student and financially dependent on the proposer. Female child can be covered until she gets married. Divorced and widowed daughters, are also eligible for coverage under the policy, irrespective of age. If the child above 18 years is financially independent or if the girl child is married, he or she shall be ineligible for coverage in the subsequent renewals.

2 2 (iii) (iv) Parents / Parents-in-law (either of them). Unmarried siblings, if financially dependent on the proposer. 2.1A INCLUSION OF NEW MEMBERS: Addition of members is allowed only at the time of renewal of the policy. However, mid-term inclusion is permitted for a newly married spouse and /or a child attaining the age of 3 months during the currency of the policy, on payment of pro-rata premium. For members subsequently added, Exclusion No. 4.1, 4.2 and 4.3 shall apply from the date of their inclusion in the policy. 2.2 SUM INSURED i. Minimum sum insured is Rs 1,00,000 and in multiples of Rs 50,000 thereafter, up to Rs 5,00,000. Beyond the Sum Insured of Rs. 5,00,000 in multiples of Rs. 1,00,000 up to Rs 10,00,000. The sum insured of each of the insured person in a policy may vary. ii. Maximum entry age (65years) under the policy can be extended upto 70 years. In all such cases, a 10% loading will be charged on the premium applicable to the age of the insured. This 10% loading will also apply on each subsequent renewal thereof. Illustration Age in completed years at the time of taking the policy for the first time on years. SI chosen Rs.4lacs Premium as per the Rate chart - Rs Premium to be charged at inception Rs % of = Rs S.Tax Renewal date Age on renewal 71 years Premium as per rate chart for age 71 years - Rs Renewal premium to be charged - Rs % of Rs = Rs S.Tax iii. iv. Maximum sum insured that can be opted by a person joining after the age of 65 years is Rs.5 lacs. Any increase in sum insured will be allowed as per iv & v below. Sum insured under the policy can be increased only at the time of renewal and at the discretion of the Company. The maximum increase allowed at each renewal is Rs. 2 lacs per insured person upto the age of 45years. Beyond 45 years, maximum increase allowed is Rs.1lac per insured person. For increased sum insured, pre-existing disease and waiting period clauses 4.1,4.2 and 4.3 of the policy, shall apply afresh. v. No increase in sum insured is allowed for insured persons above 70 years of age. Special Mention: A one time discount of 25% on renewal premium will be allowed for persons presently insured for a Sum Insured of less than Rs.1lac under Oriental s Mediclaim Insurance Policy (Individual). However, this discount is available only for insured persons opting a Sum Insured of Rs.1lac on renewal and no discount shall be allowed if the insured person opts for any higher Sum Insured.

3 3 2.3 PRE -ACCEPTANCE MEDICAL CHECKUP: Any person beyond 55 years of age proposing to take insurance cover has to submit following medical reports from listed Diagnostic Centre or any other medical report(s) required by the company in case of fresh proposal or in case of renewal where there is a break in policy period. This list is available with the underwriting office from where the policy is intended to be taken, and also displayed on Company s website. The cost shall be borne by the insured. 1 PHYSICAL EXAMINATION 2 URINE(MICROALBUMIN UREA) 3 GLYCOCYLATED HAEMOGLOBIN ULTRASONOGRAPHY (WHOLE ABDOMEN AND PELVIS) X RAY BOTH KNEES (ANTEPOSTERIOR AND LATREL) COMPLETE EYE TEST INCLUDING FUNDUS ETC STRESS TEST (TMT) In case of fresh proposals 50% cost of Medical Check up after acceptance of the proposal shall be reimbursed by the Company. This benefit will also be allowed in cases where continuity benefits are not restored and the policy is treated as fresh (and not as renewal) after the break in policy period. 2.4 COVERAGE: The policy covers reasonable and customary charges in respect of Hospitalisation and / or Domiciliary Hospitalisation for medically necessary treatment only for illness / diseases contracted or injury sustained by the Insured Person(s) during the policy period, upto the limit of Sum Insured (SI) and as detailed below A. HOSPITALISATION BENEFITS Expenses covered a. Room, Boarding and Nursing Expenses as provided by the Hospital /Nursing Home. Limits of Covered Expense Not exceeding 1 % of the Sum Insured per day. b. Intensive Care Unit (ICU) expenses as provided by the Hospital/Nursing Home. Not exceeding 2% of Sum Insured per day. Number of days of stay under a and b above should not exceed total number of days of admission in the hospital. Admissibility of all related expenses (c and d), except for medicine / pharmacy bills and body implants, shall also be as per the entitled category vis-à-vis room rent. c. Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists Fees d. Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, As per the limits of the sum insured. As per the limits of the sum insured.

4 4 Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices like Pacemaker implanted during surgical procedures, relevant laboratory / diagnostic tests, X-ray, and similar expenses. e. Ambulance service charges Rs.2,000/- OR 1% of the sum insured whichever is less per hospitalization subject to aggregate expenses not exceeding Rs. 4000/- under the policy. f. Daily Hospital Cash Allowance 0.1% of the sum insured per day subject to maximum of 6 days per insured person during the entire policy period. Deductible of 2 days shall apply for each hospitalization. g. Pre and Post hospitalization expenses Medical expenses incurred 30 days prior to hospitalisation and upto 60 days post hospitalisation. Note: 1. In case of Ayurvedic / Homeopathic / Unani treatment, Hospitalisation expenses are admissible only when the treatment is taken as an in-patient, in a Government Hospital or a hospital associated with a Medical College. 2. Relaxation to 24 hours minimum duration for hospitalization as defined in 3.8 below, is allowed in i. Day care procedures / surgeries (specified in the policy) where such treatment is taken by an insured person in a hospital / day care centre (but not the outpatient department of a hospital) ii. Or any other day care treatment as mentioned in clause 3.5 and for which prior approval from Company / TPA is obtained in writing. B. DOMICILIARY HOSPITALISATION a. Surgeon, Medical Practitioner, Consultants, Specialists Fees, Blood, Oxygen, Surgical Appliances, Medicines & Drugs, Diagnostic Material and Dialysis, Chemotherapy, Nursing expenses. 20% of the Sum Insured subject to maximum Rs.50,000 per Insured person during the entire policy period.

5 5 b. Treatment for Dog bite (or bite of any other rabid animal like monkey, cat, etc.) Maximum Rs.5,000 per incident, actually incurred on immunisation injections. This will be part of Domiciliary hospitalisation limits as given above. For the purpose of this section the conditions for domiciliary hospitalisation benefit shall not apply. Domiciliary Hospitalisation benefit shall, however, not cover expenses in any of the following cases a) if the treatment lasts for a period of three days or less b) incurred on pre and post hospitalisation treatment c) incurred on treatment of any of the following diseases : i. Asthma ii. Bronchitis, iii. Chronic Nephritis and Nephritic Syndrome, iv. Diarrhoea and all types of Dysenteries including Gastro-enteritis, v. Diabetes Mellitus and Insipidus, vi. Epilepsy, vii. Hypertension, viii. Influenza, Cough and Cold, ix. All Psychiatric or Psychosomatic Disorders, x. Pyrexia of unknown origin for less than 10 days, xi. Tonsillitis and Upper Respiratory Tract infection including Laryngitis and Pharingitis, xii. Arthritis, Gout and Rheumatism. Note: Liability of the Company under Domiciliary Hospitalisation clause is restricted as stated in Clause 2.4B. 2.5 DONOR EXPENSES: Hospitalisation expenses incurred for donating an organ by the donor (excluding cost of organ) to the insured person, during the course of organ transplant, will also be payable. However, overall liability of the Company will be limited to the Sum Insured of the insured person. 2.6 VOLUNTARY CO-PAYMENT: (OPTIONAL) i. If the insured opts for a co-payment of 10% or 20%, he is eligible for a corresponding premium discount of 10% and 20% respectively. This option is available only for insured person(s) having Sum Insured of Rs 2 lacs and above. Co-payment cannot be opted on selective basis. All insured persons under a policy have to compulsorily opt for the same (except for insured persons with Sum Insured below Rs.2lacs, where co-payment option is not available.), and the co-payment percentage has to be uniform across all insured persons. ii. Co-payment is applicable on each and every claim, which means the insured shall bear 10% / 20% (as opted by him) of each and every admissible claim. 2.7 OPTIONAL COVER (SUBJECT TO ADDITIONAL PREMIUM) A. PERSONAL ACCIDENT covering death and permanent disability (50% & 100%). Sum Insured in multiples of Rs. 2,00,000 upto Rs. 10,00,000 per insured person above 18yrs. However for persons below 18 years of age,

6 6 maximum coverage of Rs.4 lacs is allowed. EXCLUSIONS: The Company shall not be liable under this section for disablement / death of the Insured Person, i. on account of Intentional self-injury, suicide or attempted suicide ii. Whilst under the influence of intoxicating liquor or drugs iii. Whilst engaging in any hazardous activity including, but not limited to aviation or ballooning, speed contests or racing of any kind(other than on foot), bungee jumping, parasailing, parachuting, ski-diving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports or involving a military, air force or naval operations, or whilst mounting into, dismounting from or travelling in any aircraft other than as a passenger (fare paying or otherwise), in any duly licensed standard type of aircraft, anywhere in the world. iv. Directly or indirectly caused by venereal disease(s) or insanity v. Arising or resulting from insured committing breach of law with criminal intent vi. War, invasion, act of foreign enemy, hostilities( whether war be declared or not), civil war, rebellion, revolution, insurrection, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainments of people vii. directly or indirectly caused by or arising from ionizing radiations or contamination by radioactivity from any nuclear fuel, nuclear weapon material, or from any nuclear waste from the combustion of nuclear fuel, viii. Directly or indirectly caused by, contributed to, aggravated or prolonged by childbirth or from pregnancy or in consequence thereof. 2.8 FREE LOOK PERIOD- This policy shall have a free look period. The free look period shall be applicable at the inception of the fresh policy and the insured will be allowed a period of 15 days from the date of receipt of the policy to review the terms and conditions of the policy and to return the same if not acceptable. If the insured has not made any claim during the free look period, the insured shall be entitled to (i) (ii) (iii) A refund of the premium paid less any expenses incurred by the insurer on medical examination of the insured persons and the stamp duty charges or Where the risk has already commenced and the option of return of the policy is exercised by the policyholder, a deduction towards the proportionate risk premium for period on cover or Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during such period. The free look period is not applicable in case of renewal of policy. 3. DEFINITIONS: 3.1 CASHLESS FACILITY: means a facility extended by the insurer to the insured where the payments of the costs of the treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent of pre- authorization approved.

7 7 3.2 CO-PAYMENT: is a cost-sharing requirement under a health insurance policy that provides that the policy holder/insured will bear a specified percentage of the admissible claim amount. A co-payment does not reduce the Sum Insured. 3.3 DAILY HOSPITAL CASH ALLOWANCE: When an insured person is hospitalized and a claim is admitted under the policy, then the insured person shall be paid a daily cash allowance as specified above. However, a deductible of 2 days per hospitalisation shall apply, i.e Daily cash allowance will become payable from the third day onwards of continuous hospitalization. 3.4 DAY CARE CENTRE: means any institution established for day care treatment of illness and / or injuries OR a medical set -up within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under:- i. has qualified nursing staff under its employment, ii. has qualified medical practitioner (s) in charge, iii. has a fully equipped operation theatre of its own, where surgical procedures are carried out iv. maintains daily records of patients and will make these accessible to the Insurance company s authorized personnel. 3.5 DAY CARE TREATMENT: refers to medical treatment, and/or surgical procedure which is: i. undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and ii. which would have otherwise required a hospitalization of more than 24 hours. Procedures / treatments usually done in out patient department are not payable under the policy even if converted to day care surgery / procedure or taken as an in patient in the hospital for more than 24 hours. 3.6 DOMICILIARY HOSPITALISATION : means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances: i. the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or ii. the patient takes treatment at home on account of non availability of a room in a hospital. 3.7 HOSPITAL/NURSING HOME: means any institution established for in- patient care and day care treatment of illness and / or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under: i. has qualified nursing staff under its employment round the clock; ii. has at least 10 inpatient beds, in towns having a population of less than 10,00,000 and atleast 15 inpatient beds in all other places;

8 iii. has qualified medical practitioner (s) in charge round the clock; iv. has a fully equipped operation theatre of its own where surgical procedures are carried out v. maintains daily records of patients and makes these accessible to the Insurance company s authorized personnel HOSPITALISATION: means admission in a Hospital for a minimum period of twenty four (24) inpatient care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 consecutive hours. 3.9 MEDICAL PRACTITIONER: means a person who holds a valid registration from the Medical Council of any state or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of license NETWORK PROVIDER: means hospitals or healthcare providers enlisted by an insurer or by a TPA and insurer together, to provide medical services to an insured on payment, by a cashless facility PRE-HOSPITALISATION EXPENSES: means medical expenses incurred during the period upto 30 days prior to the date of admission in the hospital, provided that: i. Such Medical Expenses are incurred for the same condition for which the Insured Person s Hospitalisation was required, and ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company POST-HOSPITALISATION EXPENSES: means medical expenses incurred for a period upto 60 days from the date of discharge from the hospital, provided that: i. Such Medical Expenses are incurred for the same condition for which the Insured Person s Hospitalisation was required, and ii The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company PRE EXISTING DISEASE: means any condition, ailment or injury or related condition(s) for which the insured person(s) had signs or symptoms, and / or was diagnosed, and / or received medical advice / treatment within 48 months prior to the first policy issued by the insurer PORTABILITY: means transfer by an individual health insurance policy holder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another QUALIFIED NURSE: means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

9 3.16 REASONABLE AND CUSTOMARY CHARGES : means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved RENEWAL: Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods THIRD PARTY ADMINISTRATOR (TPA): means any person who is licensed under the IRDA (Third Party Administrators Health Service) Regulations, 2001 by the Authority, and is engaged, for a fee or remuneration by an insurance company, for the purposes of providing health services UNPROVEN/EXPERIMENTAL TREATMENT: Treatment including drug experimental therapy which is not based on established medical practice in India. 4. GENERAL EXCLUSIONS: The Company shall not be liable to make any payment under this policy in respect of any expense whatsoever incurred by any Insured Person in connection with or in respect of: 4.1 All Pre-existing Disease (whether treated / untreated, declared or not declared in the proposal form), which are excluded upto 48 months of the policy being in force. Pre-existing diseases shall be covered only after the policy has been continuously in force for 48 months. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition. This exclusion shall also apply to any complication(s) arising from pre existing diseases. Such complications will be considered as part of the pre existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to following exclusions. Diabetes Hypertension Diabetes & Hypertension Diabetic Retinopathy Cerebro Vascular accident Diabetic Retinopathy Diabetic Nephropathy Hypertensive Nephropathy Diabetic Nephropathy Diabetic Foot /wound Internal Bleed/ Diabetic Foot

10 10 Haemorrhages Diabetic Angiopathy Coronary Artery Disease Diabetic Angiopathy Diabetic Neuropathy Hyper / Hypoglycaemic shocks Coronary Artery Disease Diabetic Neuropathy Hyper / Hypoglycaemic shocks Coronary Artery Disease Cerebro Vascular accident Hypertension Nephropathy Internal Haemorrhages Bleeds/ 4.2 Any disease other than those stated in clause 4.3, contracted by the Insured person during the first 30 days from the inception date of fresh policy. This shall, however, not apply in case the insured person is hospitalised for injuries suffered in an accident, which occurred after inception of the policy. 4.3 The expenses on treatment of following ailments / diseases / surgeries, if contracted and / or manifested after inception of first policy ( subject to continuity being maintained), are not payable during the waiting period specified below. Ailment / Disease / Surgery i Benign ENT disorders and surgeries i.e. Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty etc. Waiting Period 1 year ii Polycystic ovarian diseases. 1 year iii Surgery of hernia. 2 years iv Surgery of hydrocele. 2 years v Non infective Arthritis. 2 years vi Undescendent Testes. 2 Years vii Cataract. 2 Years

11 11 viii Surgery of benign prostatic hypertrophy. 2 Years ix Hysterectomy for menorrhagia or fibromyoma or myomectomy or prolapse of uterus. 2 Years x Fissure / Fistula in anus. 2 Years xi Piles. 2 Years xii Sinusitis and related disorders. 2 Years xiii Surgery of gallbladder and bile duct excluding malignancy. 2 Years xiv Surgery of genito urinary system excluding malignancy. 2 Years xv Pilonidal Sinus. 2 Years xvi Gout and Rheumatism. 2 Years xvii Hypertension. 2 Years xviii Diabetes. 2 Years xix Calculus diseases. 2 Years xx Surgery for prolapsed inter vertebral disk unless arising from accident. 2 Years xxi Surgery of varicose veins and varicose ulcers. 2 Years xxii Congenital internal diseases. 2 Years xxiii Joint Replacement due to Degenerative condition. 4 Years xxiv Age related osteoarthritis and Osteoporosis. 4 Years If the above diseases are pre-existing at the time of inception, Exclusion no.4.1 for pre-existing disease shall be applicable. Note: If the continuity of the renewal is not maintained then subsequent cover will be treated as fresh policy and clauses 4.1., 4.2, 4.3 shall apply afresh, unless agreed by the Company and suitable endorsement passed on the policy, by the duly authorised official of the Company. Similarly, if the sum insured is enhanced subsequent to the inception of the first policy, the exclusion 4.1,4.2 and 4.3 will apply afresh for the enhanced portion of the sum insured. 4.4 Injury or disease directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War like operations (whether war be declared or not) or by nuclear weapons / materials. 4.5 Circumcision (unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to any accident), vaccination (except as covered under 2.4B(b)), inoculation or change of life

12 or cosmetic or of aesthetic treatment of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. 4.6 Surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aids etc. 4.7 Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, crowns, root canal treatment including treatment for wear and tear etc unless arising from disease or injury and which requires hospitalisation for treatment. 4.8 Convalescence, general debility, run down condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc. 4.9 All expenses arising out of any condition directly or indirectly caused by, or associated with Human T-cell Lymphotropic Virus Type III (HTLD - III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of similar kind commonly referred to as AIDS, HIV and its complications including sexually transmitted diseases Expenses incurred at Hospital or Nursing Home primarily for evaluation / diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period Expenses on vitamins and tonics etc unless forming part of treatment for injury or disease as certified by the attending physician Any treatment arising from or traceable to pregnancy, childbirth, miscarriage, caesarean section, abortion or complications of any of these including changes in chronic condition as a result of pregnancy except in the case of abdominal operation for extra uterine pregnancy (ectopic pregnancy) which is proved by diagnostic means and certified to be life threatening by the attending Medical Practitioner, if left untreated Naturopathy treatment, unproven procedure or treatment, experimental or alternative medicine (other than Ayurveda, Unani & Homeopathy as expressed in clause 2.4 A) and related treatment including acupressure, acupuncture, magnetic and such other therapies Expenses incurred for investigation or treatment irrelevant to the diseases diagnosed during hospitalisation or primary reasons for admission. Private nursing charges, Referral fee to family doctors, Out station consultants / Surgeons fees etc, 4.15 Genetic disorders and stem cell implantation / surgery Cost of external and or durable Medical / Non medical equipment of any kind used for diagnosis and or treatment including CPAP, CAPD, Infusion pump etc., Ambulatory devices i.e. walker, Crutches, Belts,Collars,Caps, splints, slings, braces,stockings etc of any kind, Diabetic foot wear, Glucometer / Thermometer, Blood Pressure monitoring machine and similar related items and also any medical equipment which is subsequently used at home. Exhaustive list available on our website (www. orientalinsurance.org.in).

13 4.17 All non medical expenses including Personal comfort and convenience items or services such as wifi/internet charges telephone, television, Ayah / barber or beauty services, diet charges, baby food, cosmetics, napkins, toiletry items etc, guest services and similar incidental expenses or services etc Change of treatment from one system of medicine to another unless agreed / allowed and recommended by the Medical Practitioner/Consultant under whom the treatment is being taken Treatment of obesity or condition arising therefrom (including morbid obesity) and any other weight control programme, and similar services or supplies Any treatment required because of Insured s participation in any hazardous activity including but not limited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing and similar other activities, unless specifically agreed and endorsed on the policy Treatment taken in an Establishment which is a place for rest, a place for the aged, a place for drug addicts or a place for alcoholics, a hotel, convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments Any stay in the hospital for any domestic reason or where no active regular treatment is given by the specialist Out patient Diagnostic, Medical or Surgical procedures or treatments, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change Massages, Steam bathing, Shirodhara and like treatment under Ayurvedic treatment Any kind of Service charges, Surcharges, Admission fees / Registration charges etc levied by the hospital Doctor s home visit charges, Attendant / Nursing charges during pre and post hospitalisation period Pre and post hospitalisation expenses unrelated with disease / injury for which hospitalisation claim has been admitted under the policy. 5 CONDITIONS 5.1 PAYMENT OF PREMIUM: The premium under this policy shall be paid in advance. No receipt for premium shall be valid except on the official form of the Company signed by a duly authorized official of the Company. The due payment of premium and the observance and fulfilment of the terms, provisions, conditions and endorsements of this policy by the Insured Person in so far as they relate to anything to be done or complied with by the Insured Person shall be condition precedent to any liability of the Company to make any payment under this policy. No waiver of any terms, provisions, conditions and endorsements of this policy shall be valid, unless made in writing and signed by an authorised official of the Company. 5.2 RENEWAL OF POLICY: The Company shall not be responsible or liable for non-renewal of policy due to non-receipt or delayed receipt (i.e. after the due date including the grace period of 30 days) of

14 premium or the proposal form or of the medical practitioners report wherever required or due to any other reason whatsoever. The Company shall not ordinarily deny the renewal of this policy unless on grounds of fraud, moral hazard, misrepresentation or non-cooperation by the insured PREMIUM REVISION: The rates applied are valid only for the period of this policy. The company may revise the premium rates and / or the terms & conditions of the policy, upon renewal thereof, only after due approval from IRDA. Renewal of this policy is not automatic; premium due must be paid to the Company before the due date. Any revision or modification in the policy will be notified to the policyholders three months in advance. 5.4 NOTICE OF CLAIM: Immediate notice of claim with particulars relating to Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease / injury and Name and Address of the attending medical practitioner / Hospital/Nursing Home etc. should be given to the Company / TPA while taking treatment in the Hospital / Nursing Home by Fax, . Such notice should be given within 48 hours of admission but before discharge from Hospital / Nursing Home, unless waived in writing. 5.5 PROCEDURE FOR AVAILING CASHLESS ACCESS SERVICES IN NETWORK HOSPITAL/NURSING HOME : i. Claim in respect of Cashless Access Services will be through the Company / TPA provided admission is in a network Hospital / Nursing Home and is subject to pre admission authorization. ii. iii. The Company / TPA reserves the right to deny pre-authorisation in case the hospital / insured person is unable to provide the relevant information / medical details as required by the Company / TPA. In such circumstances denial of Cashless Access should in no way be construed as denial of liability. Should any information be available to the Company / TPA which makes the claim inadmissible or doubtful, and warrants further investigations, the authorisation of cashless facility may be withdrawn. 5.6 CLAIM DOCUMENTS: Final claim along with documents stated in the policy, should be submitted to the Company / TPA within 15 days of discharge from the Hospital / Nursing Home. 5.7 PAYMENT OF CLAIM: All medical treatment for the purpose of this insurance will have to be taken in India only and all claims shall be payable in Indian currency only. 6. COST OF HEALTH CHECK UP: The Insured shall be entitled for reimbursement of cost of Health check up undertaken once at the expiry of a block of every THREE continuous underwriting years provided there are no claims reported during the block. The cost so reimbursable shall not exceed the amount equal to 0.75% of the average sum Insured (SI for Personal Accident section is not to be considered), or Rs.3000/- per insured person, whichever is less, during the block of THREE claim free underwriting years. This benefit is available to the insured person after three claim free years, till the expiry of the fourth year of the policy. If the benefit is not claimed in the fourth year of the policy, then in future at the time of the insured claiming this benefit, last three claim free years preceding the year in which the benefit is claimed, shall be taken into consideration.

15 15 This clause shall apply separately to each insured person i.e for any insured person, if there is no claim reported for the preceding three years, he would be eligible for this benefit even when there is a claim reported for other person(s) covered under the policy. This provision is applicable only in respect of continuous insurance without break under Oriental s Mediclaim Insurance Policy (individual). 7. CANCELLATION: Company may at any time, cancel this Policy (on grounds of fraud, moral hazard, misrepresentation or non-co-operation), by sending the Insured 30 (Thirty) days notice by registered post at the Insured s last known address; and in such an event, the Company shall refund to the Insured a prorata premium for un-expired policy period only. The Insured may at any time cancel this policy and in such event the Company shall allow refund of premium at Company s short period rate only (table given below) provided no claim has occurred during the policy period up to date of cancellation. Period on Risk Upto 1 Month Upto 3 Months Upto 6 Months Exceeding 6 months Rate of premium to be charged 1/4th of the annual rate 1/2 of the annual rate 3/4th of the annual rate Full annual rate 8. MEDICLAIM WITH OMP: In case an insured person covered under this policy goes abroad by taking Oriental s Overseas Mediclaim Policy (OMP), this Policy becomes inoperative for the period the OMP is in force while he / she is abroad. The proportionate premium under this policy for the inoperative period shall be adjusted against the renewal premium of the said insured person. The insured person must inform the company in writing before leaving India stating the details of visit(s) abroad and the OMP policy. 9. PORTABILITY: In the event of the insured person porting to any other insurer, insured person must apply with details of the policy and claims to the insurer where the insured person wants to port, atleast 45 days before the date of expiry of the policy. 10. PRODUCT WITHDRAWAL: This product may be withdrawn in future with due approval of IRDA. However, in the event of withdrawal of the product, the insured shall be informed of the options available. 11. JURISDICTION: All disputes or differences under or in relation to the policy shall be determined by the Indian Courts and according to the Indian laws. 12. DISCLOSURE TO INFORMATION NORM: The policy shall be void and in the event of misrepresentation, mis-description or non-disclosure of any material fact. 13. HOW TO APPLY FOR INSURANCE: The Proposer has to complete the proposal form and enrolment form in duplicate and submit insured person s details of each member. The proposer has to affix a coloured stamp size photographs of each of the members to be insured on the enrolment form against the name of the person. These photographs will be utilised by Third Party Administrator for preparing ID card for each of the members insured.

16 16 The contains salient features of the policy. For details, reference is to be made to the policy. In case of any difference between the prospectus and the policy, the terms and conditions of the policy shall prevail. The prospectus and proposal form are part of the policy. Hence please read the prospectus carefully and sign the same. The proposal form is to be completed in all respects for each insured person. Both the prospectus and the proposal form are to be submitted to the office or to the agent. a. Name: Signature b. Address: c. Place: Date: Note: For legal interpretation only English version will be valid. SCHEDULE OF PREMIUM: A. Basic Premium Chart SI 3 mths - 20 yrs yrs yrs Age Band in years yrs yrs yrs yrs 80 yrs plus

17 17 B. Premium for Personal Accident cover (Optional cover) Capital Sum Insured Premium Per Person Premium in the above tables is annual and in Indian Rupees. Service Tax as applicable shall be extra. Premium will be calculated on completed years as on the date of inception / renewal of the policy, eg a person who has completed 45years and 364 days, will fall in the age band of years and not in years. INSURANCE ACT 1938 SECTION 41 - PROHIBITION OF REBATE Section 41 of the Insurance Act 1938 provides as follows: Any person making default in complying with provision of this section shall be punishable with fine, which may extend to Rs.500/-. No person shall allow, or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor shall any person taking out or renewing or continuing a policy accept any rebate except such rebate as may be allowed in accordance with the published prospectus or tables of the Insurer.